Optimization of techniques in screening CT of the sinuses

The number of screening examinations of the sinuses performed with CT has markedly increased owing to the widespread and increasing use of endoscopic sinonasal surgery. We reviewed scans from 500 patients who had screening CT examinations of the sinuses for preendoscopic evaluation of inflammatory sinonasal disease to better define an optimal imaging protocol. Three aspects of direct coronal imaging of the paranasal sinuses were investigated: (1) preparation of the patient prior to the examination; (2) technical factors of the CT study, including positioning of the patient, optimal coronal angle, slice thickness, and CT exposure factors; and (3) data display. Our experience indicates that pretreatment of the patient with maximal medical therapy enables the best preendoscopic definition of anatomy, disease pattern, and nonreversible disease component for the treating surgeon. CT technical factors are optimized with scanning in the prone position with thin (3-mm) sections obtained through the anterior paranasal sinuses. This allows optimal visualization of the ostiomeatal unit. The remaining posterior portions of the sinuses are adequately imaged with thicker slices (5 mm). The coronal scan angle used is less critical. Exposure factors (mAs) can be reduced dramatically without image compromise. Data display is optimized when the bone algorithm is used to acquire the data and with image display at intermediate window center and width level. Use of the techniques outlined in this article results in a cost-effective yet diagnostic scan of the sinuses with decreased radiation exposure to the patient.

Biological and clinical effects of the combination of beta- and gamma-interferons administered as a 5-day continuous infusion

A phase I trial involving continuous infusion of both beta- and gamma-interferon (IFN-beta and IFN-gamma) was conducted in 20 patients in order to determine whether combinations of high doses of IFN-beta and IFN-gamma were tolerable when administered under conditions which mimic conditions of in vitro antiproliferative studies. Patients received a 5-day continuous infusion of IFN-beta/IFN-gamma, followed by a 9-day rest period. Two cycles were administered. Doses of IFN-beta/IFN-gamma were escalated between 4 dose levels, with 5 patients per dose level. Dose-dependent side effects, consisting primarily of constitutional symptoms typical of those experienced with IFN, were observed. The maximally tolerated dose of continuous IFN-beta/IFN-gamma infusion was 3 x 10(6) units of IFN-beta and 200 micrograms of IFN-gamma. Dose-limiting side effects consisted of severe headache, fatigue, fever, and hepatic toxicity. No clinical responses were observed. Serum IFN was measurable only at the highest 3 dose levels. Only 5 patients (4 at the highest dose level) had total serum levels which exceeded 50 laboratory units/ml (55, 63, 800, 800, and 550 laboratory units/ml, respectively). In order to confirm the biological effectiveness of this schedule, we measured IFN-inducible proteins prior to therapy, 24 h after the initiation of the infusion, and at the completion of the 5-day infusion. 2'-5'-Oligoadenylate synthetase, serum beta 2-microglobulin, neopterin, and p78 levels all increased significantly, and serum tryptophan decreased significantly within 24 h after the initiation of treatment (P less than 0.0001). A dose-response effect was observed for serum beta 2-microglobulin, neopterin, and p78 (P less than 0.02). We retrospectively compared the results of this trial with those of another IFN-beta/IFN-gamma trial in which IFN-beta and IFN-gamma were administered by i.v. bolus. Within the limitations of a retrospective comparison, continuous infusion was less well tolerated than our previous schedule of bolus administration 3 times/week. However, the continuous infusion schedule appeared to be more effective in enhancing 2'-5'-oligoadenylate synthetase levels in mononuclear cells. We conclude that tolerable doses of IFN-beta and IFN-gamma do not result in serum IFN levels which produce significant synergistic antiproliferative responses in vitro. This study and other findings suggest that, unless higher doses can be achieved, combinations of IFN-beta and IFN-gamma are unlikely to have significant therapeutic activity.

EEG sleep in adolescents with major depression: the role of suicidality and inpatient status

All night sleep EEG recordings were performed for three consecutive nights in 27 adolescents with a diagnosis of major depressive disorder (MDD) and 30 normal adolescent controls. Group comparisons between the entire MDD group and the normal controls revealed no significant diagnostic group differences for any of the major sleep variables. Analyses within subgroups of MDD adolescents, however, revealed heterogeneity of EEG sleep findings in association with suicidality and inpatient status. The findings of this study suggest that the discrepancies among the EEG sleep studies in adolescent MDD may be accounted for by the relative proportions of inpatients, suicidality, or bipolarity within the MDD sample being studied.

Participation of nurse executives in product decisions

This national survey of 30 chief nurse executives documented the significant product purchase power of these administrators. While nurse executives in small organizations tended to be involved in almost all product decisions, nurse executives in larger institutions focused on major hospital equipment purchases.

Cortisol secretion in adolescents with major depressive disorder

Plasma cortisol concentrations were determined every 20 min for 24 h, in a nonstressful environment, among 48 rigorously assessed, mostly outpatient, drug-free adolescent subjects during an episode of major depression (MDD) and among 40 normal adolescent subjects. There were no significant differences in the 24-h mean, peak, or nadir, or the time of the nocturnal rise, in plasma cortisol in the 2 groups. Analyses of different subgroups of MDD adolescents according to suicidality, severity of depression, separation anxiety, psychotic subtype, endogenicity, duration of episode, and sex also revealed no significant group differences. Only one adolescent (with MDD) was identified clearly as a hypersecretor of cortisol. These results indicate that abnormalities of spontaneous cortisol secretion are an unusual finding among adolescents with major depression when studied in a nonstressful environment.

Implementing differentiated practice: the Sioux Valley Hospital experience

Historically, nurses with different levels of education have been used interchangeably in acute care hospitals. If nursing is going to be viewed as a preferred career choice and acute care hospitals are to retain staff, nurse administrators must provide a nursing practice model that differentiates scope of practice based on education. The authors discuss how they implemented a system of differentiated practice.

Failure of prediction of liver function test abnormalities with the urine urobilinogen and urine bilirubin assays

A prospective observational study of 229 cases was conducted in a busy ambulatory care setting to evaluate the sensitivity, specificity, predictive values, and accuracy of spot urine urobilinogen and urine bilirubin assays as screening tests for serum liver function test (LFT) abnormalities. Both urine tests exhibited remarkably similar characteristics overall once they were adjusted to maximize accuracy and predictive values (occurring at a normal or abnormal "threshold," respectively, of 3.4 or 5.07 mumol/d for urobilinogen and 0 or 1+ for urine bilirubin). The percentage of cases correctly identified were 81% to 83% for serum bilirubin assays, 68% to 72% for other LFTs, but only 62% to 63% for screens for cases with at least one abnormal LFT finding. Poor sensitivities (47% to 49%) limited the detection of abnormal findings by the screen; both screens were reasonably specific (79% to 89%), but negative predictive values were suitable (89%) for serum bilirubin results only and were prohibitively lower (49% to 50%) in predicting all patients without LFT abnormalities. We conclude that spot urine urobilinogen and urine bilirubin determinations, although good screens for isolated serum bilirubin elevations, have unacceptable statistical properties as predictors of other LFT results due to a high proportion of false-negative results.

Growth hormone response to desmethylimipramine in depressed and suicidal adolescents

Desipramine 75 mg i.m. was given in the morning to 20 adolescents with major depressive disorder and 23 normal controls. Depressed adolescents secreted significantly less growth hormone (GH) over the next 2 h than did normal adolescents, although a substantial proportion of the differences were accounted for by the depressed adolescents who had a specific suicidal plan or attempt during the episode. Severity of depression or the presence of other depressive symptoms did not predict GH secretion within the depressed group. Age, sex and maturational factors in the control of GH are discussed. It is concluded that these differences in GH secretion probably reflect differences in CNS beta-adrenergic and/or serotonergic function. Suicidality and depression may have different psychobiological correlates in adolescents.

Usefulness of the stool Wright's stain in the emergency department

A prospective study was conducted to determine if a Wright's stain of stool specimen to detect fecal leukocytes was accurate in predicting the presence of a bacterial pathogen on stool culture. Entry criteria were patient age greater than or equal to 3 months and diarrhea of greater than 1 day. The patient population was drawn from an urban county hospital emergency department on the Texas-Mexican border. A total of 69 patients were evaluated by both routine stool culture and stool Wright's stain. Twenty-three were evaluated for parasitic pathogens. There were seventeen cultures positive for bacterial pathogens and twenty-three positive Wright's stains. Bacterial isolates included Shigella, Salmonella and Campylobacter. Also detected were Giardia, Shistosoma, Blastocytis and Cryptosporidium. The sensitivity of a Wright's stain positive for fecal leukocytes for the presence of a bacterial pathogen by culture was 82%, with a specificity of 83%. These were significantly correlated with a positive culture for a bacterial pathogen (P less than .01). The predictive value of a positive result was 61%, and predictive value of a negative result was 94%, for bacterial pathogens. The Wright's stain is a useful tool for the early presumptive diagnosis of infectious bacterial diarrhea in the emergency department.

Abnormalities of urine urobilinogen and urine bilirubin assays and their relation to abnormal results of serum liver function tests

A prospective observational study of 324 cases was conducted in a busy ambulatory care setting to evaluate the sensitivity, specificity, predictive values, and accuracy of spot urine urobilinogen and urine bilirubin assays as screening tests for serum liver function test (LFT) abnormalities. High positive predictive values (88% for at least one abnormal LFT) make the evaluation of positive urine screens detected during routine health care maintenance examinations imperative. Because extraneous factors may influence both urine and serum test results, however, urine assays obtained as a screening parameter in clinical presentations (abdominal pain, jaundice, constitutional symptoms, etc) have only limited clinical utility. The high proportion of false-negative results for both urine assays renders their statistical properties unacceptable as screens in these clinical situations.

Comparative, multicenter studies of cefixime and amoxicillin in the treatment of respiratory tract infections

A total of 560 patients were treated in two double-blind, randomized multicenter studies to compare the safety and efficacy of cefixime (400 mg administered once daily) and amoxicillin (250 or 500 mg administered three times daily) for the treatment of bacterial respiratory tract infections. Eighty percent of the 244 patients treated in the lower respiratory tract infections (LRTI) study had acute bronchitis. Streptococcus pneumoniae (13 percent), Haemophilus influenzae (28 percent), and Escherichia coli (10 percent) were the pathogens most frequently isolated from sputum in these patients. Among evaluable patients with positive bacterial culture results at baseline, a favorable clinical response (cured or improved) was obtained in 100 percent of the cefixime-treated patients (22 of 22) and in 96 percent of the amoxicillin-treated patients (23 of 24). Bacteriologic eradication rates were 100 percent and 83 percent for cefixime and amoxicillin, respectively. In the upper respiratory tract infections (URTI) study, 316 patients with pharyngitis (80 percent) or tonsillitis (14 percent) were treated. Group A, beta-hemolytic Streptococcus (69 percent) and H. influenzae (8 percent) were the pathogens most frequently isolated from the throat culture specimens of these patients. Favorable clinical results were obtained in 99 percent of the evaluable cefixime-treated group (n = 73) and in 98 percent of the amoxicillin-treated group (n = 66). The bacteriologic eradication rates were 93 percent and 100 percent, respectively. The adverse experiences reported during both studies were similar in nature and frequency to those reported for other beta-lactam antibiotics with the exception of a higher incidence of altered bowel movement (diarrhea and stool changes) with both drugs. These episodes usually resolved without remedial medication when the treatment was withdrawn. No significant adverse laboratory findings were observed. Results of these trials demonstrate that cefixime at a dosage of 400 mg once daily is an effective and safe oral antibiotic for the treatment of acute respiratory tract infections.

Development, implementation, and evaluation of a medical Spanish curriculum for an emergency medicine residency program

A 45-hour medical Spanish curriculum for an emergency medicine residency program was implemented in response to a need for "functionally bilingual" physicians in our practice setting, and to reduce reliance on translation assistance from nursing and clerical personnel. Course goals were to achieve a vocabulary level of 5,000-10,000 words for participants, and to achieve sufficient language capabilities for basic information exchange, obtaining uncomplicated medical histories, conducting unassisted physical examinations, and giving patient discharge instructions. Feedback obtained from post course interviews and instructor assessment indicated that the curriculum employed resulted in the attainment of the above goals for fully participating physicians.

Vibrio vulnificus septicemia

We report a case of Vibrio vulnificus infection in a middle-aged alcoholic man with Laennec's cirrhosis. The patient had recently received a puncture wound from the shell of a shrimp while fishing in the Gulf of Mexico. He presented with acrally distributed urticarial plaques, purpura, and bullae, as well as signs and symptoms of septic shock. Vibrio vulnificus was isolated from the blood, and histologic examination of the skin biopsy specimen demonstrated a devitalized, inflammatory, cell-poor superficial dermis and an acute cellulitis of the subcutis, with extensive tissue destruction. In addition, a necrotizing vasculitis, with a relative paucity of inflammatory cells but numerous bacilli around dermal vessels, was noted.

The clinical picture of major depression in children and adolescents

Symptom frequency and severity were compared in two sequential clinically referred samples of 95 children and 92 adolescents, aged 6 to 18 years, all medically healthy, assessed with the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present Episode, who met unmodified Research Diagnostic Criteria for major depressive disorder (MDD). There were no significant differences between the two groups in the majority of depressive symptoms. However, prepubertal children had greater depressed appearance, somatic complaints, psychomotor agitation, separation anxiety, phobias, and hallucinations, whereas adolescents had greater anhedonia, hopelessness, hypersomnia, weight change, use of alcohol and illicit drugs, and lethality of suicide attempt, but not severity of suicidal ideation or intent. Adolescents with a duration of the depressive episode of two years or greater had significantly higher rates of suicidal ideation and intent, lethality, and number of suicide attempts than youngsters with depressive episodes of shorter duration. A principal components factor analysis of psychiatric symptoms was carried out in all 296 youngsters evaluated during the same period who met DSM-III criteria for any Axis I diagnosis. The majority had an affective disorder. Factors were quite similar for both adolescents and children and included an "endogenous" and an "anxious" factor, as in many studies of adult depression. In addition, three other factors were found: negative cognitions, appetite and weight changes, and a conduct factor. Suicidal ideation was a component of both the negative cognitions factor and the conduct factor.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of the dexamethasone suppression test (1 mg and 2 mg) to basal plasma cortisol levels in endogenous depression

The 1 mg and 2 mg dexamethasone suppression tests (DST) were evaluated in two groups of endogenously depressed patients (n = 39 and n = 30, respectively) who also had a 1300-1600 hr basal cortisol assessment. Non-suppressors (on both DSTs) had significantly higher basal plasma cortisol levels and thus were significantly associated with relative cortisol hypersecretion. However, there was only a partial overlap between DST response and basal plasma cortisol, with a large variation of cortisol levels among non-suppressors. The 2 mg DST appears to be more specific for cortisol hypersecretion than the 1 mg DST. If cortisol hypersecretion is to be identified, neither the 1 mg or 2 mg DST is an adequate assessment nor a substitute for a basal cortisol assessment.

Electroencephalographic sleep of adolescents with major depression and normal controls

Forty-nine, mostly outpatient (86%), nonbipolar adolescents, aged Tanner stage III to 18 years, with a current diagnosis of major depressive disorder and 40 adolescents without current presence or history of psychiatric disorder were studied polysomnographically for three consecutive nights. Sleep latency was significantly longer in the depressive groups. The nonendogenous depressive patients exhibited significantly more awake time and lower sleep efficiency during the sleep period. No significant group differences were found for first rapid eye movement (REM) period latency, REM density, or any other REM sleep measures. Age correlated significantly with REM latency and delta sleep time, especially among depressive patients. No significant correlations between sleep measures and severity of illness were found. It appears that the classic REM sleep findings associated with the adult depressive syndrome are not present among depressive adolescents, indicating a later ontogeny for these abnormalities.

Rapid diagnosis of group A strep pharyngitis in the emergency department

Two ten-minute rapid tests for diagnosing Group A streptococcal pharyngitis in 147 emergency department patients with a complaint of sore throat were evaluated using positive throat cultures as the marker for disease. Treatment was initiated solely on the basis of clinical judgment. Sensitivity and specificity were 78% and 93%, respectively, for the rapid test and 69% and 56%, respectively, for clinical judgment. The rapid test was significantly better than clinical judgment alone in determining the presence of disease (P less than .05). The predictive values of the positive and negative and were 78% and 93%, respectively, for the rapid test and 38% and 85%, respectively, for clinical judgment. In the ED setting in which adequate followup is difficult, the rapid test can identify more accurately than can clinical judgment alone those patients who need therapy.

Microglandular hyperplasia of the uterine cervix

Forty-three cases of microglandular hyperplasia of the cervix seen during a 3.5-year period are reported. The series is unusual in that more than one-half of the patients had no history of oral contraceptive use and three patients were postmenopausal. Additionally, evidence of estrogenic stimulation was present in eight cases. The role of estrogens and progestogens in the development of microglandular hyperplasia is discussed. The authors consider microglandular hyperplasia to be an unusual and florid form of reserve cell hyperplasia with glandular differentiation.